Head pain—headache and facial pain included—is some of the most debilitating pain a person can experience. There are a variety of causes of this type of pain, but one of them in particular can be difficult to properly diagnose. What is occipital neuralgia? Here’s what you need to know about this serious pain condition.

What is occipital neuralgia?

Occipital neuralgia is a type of head and facial pain that originates in the occipital nerve. Your occipital nerve is actually a group of three nerves that originates from the cervical spine (the neck).

They include the:

• Greater occipital nerve (GON): Innervates the back of the scalp, the ear, and a portion of the skin
• Lesser (small) occipital nerve (LON): Has three divisions (auricular, mastoid, and occipital branches) that innervate the head behind the ear and where the ear attaches to the head
• Third (least) occipital nerve (TON): Runs on either side of the cervical vertebrae and innervates the back of the head

Occipital neuralgia is the pain condition that results when these nerves are damaged or compressed. This damage or compression may occur to the nerve itself, or it may be a result of other injuries that involves nearby nerves. For example, injuries to the neck and shoulders can lead to occipital neuralgia.

What causes occipital neuralgia?

Occipital neuralgia causes can all be traced back to irritation or inflammation of the occipital nerves. And, while this condition itself is not a life-threatening condition, the pain of it can make daily life incredibly challenging.

But what causes this irritation? These are some of the more common causes.

Whiplash

Whiplash is a traumatic injury in which the head and neck is thrust forward until it reaches the end of its range of motion before snapping violently back. This motion can cause severe injury to the tendons, ligaments, and muscles of the neck.

This is one of the most common causes of occipital neuralgia.

Injury to the head and neck

Any injury other than whiplash can cause damage to the occipital nerve and result in occipital neuralgia.

This may occur during a fall or an injury while playing sports.

Stiff neck muscles

Stiff neck muscles may be the result of an ongoing forward head position.

If you work in a job that has you staring at a screen or looking downwards on a regular basis, you may experience stiff neck muscles that begin to compress one or more occipital nerves.

Arthritis

All joints in the body are susceptible to arthritis, and the cervical spine is no different.

Inflammation due to wear and tear, or due to autoimmune conditions, can cause the characteristic pain of occipital neuralgia.

Gout

Gout is not a common cause of occipital neuralgia, but it can occur.

It’s is a type of arthritis that occurs when uric acid collects in the joints. This collection can cause inflammation and pain.

Diabetes

Those with diabetes are at an increased risk of headaches and head pain related to damage to their vascular system.

This is because poorly controlled diabetes can result in highly variable blood sugar that damages veins. Although diabetic pain is usually confined to the lower extremities, it can occur in the form of occipital neuralgia as well.

Inflamed blood vessels

This is not a common cause of occipital neuralgia, but it can occur.

Inflamed blood vessels anywhere on the neck or scalp can press on the occipital nerve, causing symptoms.

Tumors and infections

Tumors along the neck and spine or infections in that same region may result in nerve compression or inflammation along the muscles of the neck and shoulders. These two causes of occipital neuralgia are rare.

Do I have occipital neuralgia?

Now that we’ve answered the question “what is occipital neuralgia?” it’s time to look at who is most at risk for developing this condition.

Common risk factors for occipital neuralgia include those with a history of:

• Infection of muscles and nerves in the neck, shoulders, and upper back
• Trauma to the neck or head (e.g., car accident)
• Cervical osteoarthritis (osteoarthritis in the neck)

Further, it’s important to recognize occipital neuralgia symptoms for the best chance of treatment success. By getting treatment early, you can help reduce worsening of symptoms.

Occipital neuralgia symptoms

The most common occipital neuralgia symptoms include:

• Pain: Pain can be sudden, severe, and sharp. It can occur behind the eye, at the base of the head, and on one side of the head. This pain can have a variety of qualities. Most patients describe it as sharp and sudden. Pain can also radiate towards the face as the condition worsens.
• Sensitivity: Sensitivity to all forms of stimulation is common. This includes sensitivity to light and touch. Tenderness to touch is usually felt directly over the involved nerve. Simple acts like brushing your hair can become excruciating.
• Issues with balance, coordination, and speech: Dizziness and vertigo are troubling symptoms that make daily life harder. Blurry vision contributes to difficulties with balance as well. Slurred speech is one of the more troubling symptoms. When combined with balance issues, it can resemble the aftermath of a stroke.
• Nausea and vomiting: It makes sense that dizziness and vertigo can lead to nearly constant nausea and, in some severe cases, vomiting.
• Tightness in the neck: Increasing tightness in the neck (with or without pain) might be the first symptom of occipital neuralgia. It can occur gradually or come on suddenly after an injury, almost like a muscle spasm.
• Dental pain: The occipital nerve innervates the area around the ear. As with ear infection, patients with occipital neuralgia may feel pain in their back teeth.

These symptoms alone can indicate other conditions, but together they provide the landmarks for an occipital neuralgia diagnosis.

Diagnosing occipital neuralgia

Some occipital neuralgia symptoms are similar to migraine symptoms. This in and of itself makes diagnosing occipital neuralgia quite challenging. There is no singular test that diagnoses this condition, so your doctor will proceed with a standard course of testing to eliminate some conditions and begin to narrow down the possibilities.

These tests may include:

• Physical examination
• Neurological testing
• Magnetic resonance imaging (MRI)
• Computed tomography scan (CT or CAT scan)

Occipital nerve blocks are also used as not only a treatment (see below) but also as a diagnostic tool. If a block in the occipital nerve relieves your pain, it can help confirm the diagnosis.

How do you treat occipital neuralgia?

Occipital neuralgia treatments aim at reducing symptoms while treating underlying causes of pain as well. As everyone’s pain (and situation) is different, not everyone will find relief with every treatment.

The best course of action is to work closely with your pain specialist to find a comprehensive treatment plan that addresses the physical and mental side effects of occipital neuralgia. These are the most common occipital neuralgia treatment options.

Keep in mind that many of these options can and should be combined for best results. For example, your doctor may prescribe medications or interventional treatments for acute pain management and then put you on a therapy regimen to manage your pain long-term.

1. Change your diet

Just changing your diet will not fix the issues causing your occipital neuralgia, but it can provide support. Anti-inflammatory diets help the body reduce inflammation, which can relieve pain.

2. Work on stress relief

Chronic stress is a chronic problem that can lead to tight shoulders and neck and, yes, occipital neuralgia. Stress-relieving meditation (mindfulness meditation or sleep-improving yoga nidra) can help you release chronic stress.

3. Explore massage

If your skin is sensitive to touch, massaging the neck is a no-no. Massaging the upper back and shoulders, though, may be a good way to relax those tight muscles first to allow the neck to unclench.

4. Exercise

Hard-hitting, fast-paced exercise may be one option to relieve stress, but you may also want to explore slower, more meditative workouts like yoga and tai chi.

5. Attend physical therapy

Your physical therapist can prescribe specific exercise that strengthen the supporting muscles in your shoulder and neck. This can counteract the effects of years of slumping over a desk. They can also help release tension and tight muscles leading to pain.

6. Use over-the-counter medications

Non-steroidal anti-inflammatory drugs like ibuprofen are an option for relieving pain and inflammation. Taken as directed, they may be the key to providing enough relief to attend physical therapy sessions or receive other treatments.

Topical over-the-counter medications and patches can also help.

7. Explore prescription medication

There are prescription medications that can help relieve the pain of severe occipital neuralgia. These include:

• Antidepressants
• Anti-convulsant medications
• Muscle relaxants

It is important to note that opioids are not indicated in the treatment of chronic pain.

8. Consider acupuncture

Acupuncturists place hair-thin needles at specific spots in the body to open energy channels and release pain-relieving endorphins.

Treatments are minimally invasive and are a great complementary treatment option.

9. Talk to a chiropractor

In cases where spinal misalignment is causing your pain, chiropractic care can help. Using manual techniques or special tools, a chiropractor can help restore balance in the spine.

10. Work on proper mechanical function

Mechanical function is the way in which you use your body and walk, sit, and otherwise move through the world. Improving your mechanical function through posture training and gait analysis can help.

Further, at work, make sure all of your office furniture is ergonomically supportive to help you maintain good mechanical function throughout your day.

11. Consider occipital nerve blocks

Occipital nerve blocks are a diagnostic tool that can also provide significant pain relief. A numbing agent and a steroid are injected into the affected nerve. This provides relief from both pain and inflammation, while also diagnosing the source of your pain.

12. Ask about radiofrequency ablation

Radiofrequency ablation (RFA) uses heat to damage any affected nerves and relieve pain. This damage affects pain signaling, and the effects can last for months.

13. Look to Botox for relief

Some patients find that Botox relieves their occipital neuralgia symptoms. Used mostly for headaches and migraines, there is growing evidence that Botox may be helpful in treating head pain related to occipital neuralgia.

14. Investigate surgical options

Surgery is usually a last resort when more conservative treatments have been unsuccessful. If your pain is unrelieved and your daily life is being negatively impacted, talk to your doctor about specific procedures that might help.

Get help for occipital neuralgia

What is occipital neuralgia? It’s a complex pain condition that can be challenging to diagnose and treat, but there is help.

At Arizona Pain, we work with you to diagnose the cause of your pain and to help you get your life back. If you are struggling to find relief, get in touch today.

Imagine a condition where brushing a stray hair off of your cheek causes excruciating and debilitating pain, pain that is unresponsive to pain medication and lasts long after the light touch has stopped. This is a brief glimpse into the mysterious pain of trigeminal neuralgia. Understanding what causes trigeminal neuralgia can lead to a proper diagnosis and successful treatment of pain. Here’s what you need to know.

What is trigeminal neuralgia?

Trigeminal neuralgia is a type of neuropathic (nerve related) pain that stems from the trigeminal nerve. This nerve has three branches that bring sensation to different parts of the face. These include:

1. Upper: Controls sensation in the eye, upper eyelid, and forehead
2. Medial: Sensation control in the lower eyelid, cheek, nostril, upper lip, and upper gum
3. Lower: Responsible for feeling in the jaw, lower lip, lower gum, and inside the mouth

Each branch originates between the end of the lower jawbone and the ear, right where the temporomandibular joint comes together. Trigeminal neuralgia pain is most often felt on one side of the face but can occur bilaterally (on both sides) as well.

Atypical trigeminal neuralgia includes a variety of other symptoms and may coincide with overlapping conditions, such as temporomandibular joint disorder.

An estimated 150,000 people in the U.S. receive a trigeminal neuralgia diagnosis each year. Commonly misdiagnosed as migraine, trigeminal neuralgia may, in fact, affect many more people than previously thought.

Do I have trigeminal neuralgia?

In the early stages of trigeminal neuralgia, trigeminal neuralgia symptoms may be sporadic and fleeting. Because there is no regularity to them, patients may not seek immediate treatment. Shooting pain and spontaneous pain not traced to a particular cause may be the first symptoms that occur. They may disappear as suddenly as they arrive, making a person believe the pain was caused by something episodic (e.g., a sudden movement or slight injury).

Other early trigeminal neuralgia symptoms may include:

• Ear pain
• Nausea
• Fatigue
• Sensitivity to light

These are similar to symptoms experienced by migraine sufferers and may lead to an incorrect diagnosis. When symptoms are treated as migraine pain, they will continue and worsen.

As symptoms get worse, patients may experience episodic pain. This occurs with increasing regularity as patients endure an intense period of pain followed by remission. As nerve damage worsens, so does the pain and periods of remission get shorter.

In some cases, patients begin to experience a constant ache or burning sensation. For patients who do not experience a constant dull ache, increasingly frequent attacks occur. This pain will be unresponsive to any type of pain medication and is uneven in its duration.

Symptoms are different in their onset, severity, and response to treatment from patient to patient due to the cause of the pain and any comorbid conditions that might complicate an accurate diagnosis.

What causes trigeminal neuralgia?

Trigeminal neuralgia is challenging to diagnose because no one thing causes pain 100% of the time in every patient. A potential cause in one person may not produce any pain in another.

However, here are some of the more common trigeminal neuralgia causes:

• Damage to the trigeminal nerve: Any kind of blow or injury to the jaw can potentially damage the trigeminal nerve. This damage can cause excruciating pain while the injury heals.
• Nerve compression: Nerve compression caused by a tumor or other mass of tissue is not the most common cause but does occur in some patients. Tumors can be benign and still press on the nerve, causing pain.
• Multiple sclerosis: Multiple sclerosis causes damage to the myelin sheath, the protective coating on the trigeminal nerve. Once this sheath is compromised or worn, exposing the nerve, pain can occur.
• Scleroderma: Scleroderma is a very rare chronic connective tissue disorder that is classified as an autoimmune condition. Among other symptoms, trigeminal pain can occur in later stages.
• Shingles (herpes zoster): Shingles is a viral infection of the nerves. Common symptoms include a raised, painful rash and, less typically, trigeminal neuralgia pain. Trigeminal pain generally occurs when the shingles rash in located near or on the head, face, or neck.
• Deformity in the arteries and veins: Tangled arteries and veins that become swollen with blood can compress the trigeminal nerve.

What are trigeminal neuralgia risk factors?

Age and gender are primary risk factors, as women over the age of 50 are most likely to develop this condition. Hypertension (high blood pressure) is also a risk factor, as is the occurrence of a stroke.

Excessive or improper dental work can cause neuropathic facial pain, as can surgery on the sinuses.

Finally, any blow or injury to the face (i.e., as a result of a contact sport injury) is a risk factor for trigeminal neuralgia.

What causes trigeminal neuralgia to flare up?

One of the most challenging aspects of trigeminal neuralgia is how sensitive the pain response becomes. Even the lightest stimulation of the painful area can produce lightning bolts of pain across the face.

Some common trigeminal neuralgia triggers include:

• Shaving
• Touching your face
• Eating
• Drinking
• Brushing your teeth
• Talking
• Putting on makeup
• A breeze on the face
• Rising or falling barometer
• Showering
• Smiling (or frowning)
• Increase in blood pressure
• Cold weather
• Drinking alcohol
• Stress
• Washing your face

Oral surgeries and even a regular dental cleaning can also be major triggers, causing some patients to neglect their oral health.

Based on this list of major pain triggers, it is easy to see how trigeminal neuralgia can become debilitating, make everyday life excruciatingly painful.

How to treat my pain

It is important to understand that traditional pain treatments are generally ineffective for this type of neuropathic pain. Why this is so is not well understood, but it is one of the main reasons that people suffering from trigeminal neuralgia can feel hopeless about treatment.

Proper diagnosis is key, however, and there are treatment options that can help you manage and reduce your symptoms.

Trigeminal neuralgia diagnosis

Due to the debilitating severity of pain and its accompanying symptoms, trigeminal neuralgia is sometimes referred to as the suicide disease. Patients who experience this condition have a higher rate of suicide and a greater risk of depression and anxiety. Getting a proper diagnosis is key to treating this disease, and it starts with a complete medical history, including identifying any risk factors.

Other conditions such as temporomandibular joint disorder, cluster headaches, migraine, and post herpetic neuralgia will be ruled out first. In some cases, an MRI looks for tumors pressing on the trigeminal nerve.

Your doctor will also rule out any issues with the sinus cavity, eye conditions, or psychologic disorders. Essentially, absent a visible tumor pressing on the nerve, the process of elimination is what leads to a proper diagnosis.

In some cases, a short course of tricyclic antidepressants or anticonvulsant medication may be administered. If pain responds to these treatments, that may lead to a diagnosis of trigeminal neuralgia.

Trigeminal neuralgia treatments

Trigeminal neuralgia treatments begin most often with medication, but not pain medication. Both over-the-counter and prescription pain medications produce little if any pain relief and are more associated with side effects than analgesic effects. Three types of prescription medications instead – anticonvulsants, antidepressants, and muscle relaxants – are the first line of pharmacological defense for trigeminal neuralgia.

Anticonvulsant options include the following four medications.

1. Carbamazepine

The most common medication for treating trigeminal neuralgia, carbamazepine can help with pain in the earliest stages of trigeminal neuralgia. This medication is also used as a diagnostic test. If carbamazepine relieves pain when administered over a short period of time, this may be a sign of trigeminal neuralgia.

This medication is most effective in the early stages of trigeminal neuralgia, and its effectiveness decreases over time.

2. Phenytoin

Phenytoin is the first medication designed to treat trigeminal neuralgia. Note that there are side effects that may include gum overgrowth, balance issues, and drowsiness.

3. Oxcarbazepine

Oxcarbazepine is a cousin of carbamazepine but comes with fewer side effects. Although patients may experience dizziness and double vision, these side effects are usually mild and manageable.

4. Gabapentin

Gabapentin is an anticonvulsant that is also prescribed for anxiety, restless leg syndrome, and withdrawal from some types of drugs and alcohol. Side effects of this medication include increased hostility, motion sickness, and blurred vision.

Antidepressants

Antidepressants are also commonly used to treat trigeminal neuralgia (although the mechanisms behind how they work is not entirely clear).

Tricyclic antidepressants such as amitriptyline or nortriptyline may successfully reduce or eliminate painful outbreaks. They can also help relieve other related symptoms.

If medication does not relieve pain, more interventional approaches may be needed.

Interventional approaches

If the cause of your trigeminal pain is compression of the nerve, microvascular decompression may help. The microvascular decompression procedure identifies the blood vessel applying pressure and moves it away from the trigeminal nerve. This can decrease nerve sensitivity and give the trigeminal nerve the space it needs to repair itself.

While microvascular decompression can be remarkably effective, opening the skull to perform it comes with substantial risk, including facial numbness and weakness and potential hearing loss.

Lesioning techniques is another category of surgical intervention that can help relieve pain. These include:

• Percutaneous stereotactic rhizotomy: Percutaneous stereotactic rhizotomy uses heat that passes through an electrode and into the trigeminal nerve to destroy the pain-causing part of the nerve and block pain signals to the brain
• Percutaneous glycerol rhizotomy: Glycerol performs the same function as heat to block pain signal transmission to the brain
• Stereotactic radiosurgery (also known as gamma knife): A pinpointed dose of ionizing radiation to the trigeminal nerve roots causes a pain-blocking lesion to form
• Percutaneous balloon compression: A small balloon is temporarily placed in the trigeminal nerve itself, inflated to destroy pain-causing fibers within the nerve

The above lesioning techniques are less invasive than an open surgery, but the effects may not be permanent. All surgeries come with risks, and lesioning techniques are no different. Side effects and risks include lingering soreness, nerve damage, or infection.

Even if pain relief is not as long-lasting, lesioning techniques may be best for patients who are in otherwise poor health, suffer from severe pain, and cannot tolerate a more invasive procedure.

Other treatment options

Experimental treatments using sodium channel blockers are also having some success in treating trigeminal neuralgia related to multiple sclerosis, but this research is in its infancy.

Complementary approaches including biofeedback, firm facial massage (as tolerated), mindful meditation, and acupuncture may also help relieve the pain of trigeminal neuralgia.

If you have more questions about what cause trigeminal neuralgia and how to treat it, get in touch with Arizona Pain today. Our gentle, compassionate doctors can answer your questions and help you get your life back!